WGU- Classification Systems - C808
Examination (2025-2026) Version with Questions
and Answers / Already Graded A+
Copy/Paste Functionality
Should be prevented by creating organizational policies. Problem with
this occurrence accuracy of the health record, certify the record as a
legal document when the original source is difficult to establish, and
disclosure of information to the wrong patient.
Record Retention Policies
Allows the HIM professional to know what data needs to be
maintained.
Patient Identity Management
Is a huge issue in today's connected environment. Ensuring that the
right patient is connected with the right information relies on accurate
patient identity management. Master Patient Index (MPI)
(Note: The care provider is responsible for ensuring that EHR entries
are High Quality.)
EHR Entry Policies
1. Entries must be authenticated and dated ( Name + Status)
2. All paper entries should be in ink
3. No erasures or deletions should be made
4. If correcting a paper record, one like should be drawn neatly
thought the error, leaving the incorrect material legible. The error
should be initialed and dated. In an EHR the error should be noted +
hidden. ( not deleted)
,5. Original reports should be always kept. Scans + lab results may be
replaced.
6. No blank spaces in process and nurse notes. If blanks mark with an
X.
7. All blanks should be completed. Especially, on consent forms.
8. When health records are filed incomplete, a statement should be
attached to indicate the case, signed by chief of staff or chair of the
health record committee.
9. Chart folder labeling, dotting, or other methods of identifying at a
glance a particular type of patient, such as one with a drug or alcohol
diagnosis or HIV- Positive status, should be discouraged to prevent
inadvertent breaches of confidentiality.
Advance Directive
A written document, such as a living will, that states the patient's
preferences for care in the event that the patients condition prevents
him or her from making care decisions.
Durable Power of Attorney
Is a document that names someone to make decisions from the
patient if the patient is unable to make these decisions. The person is
often called a proxy. Goes into effect when the physician determines
the patient is no longer able to communicate about health care
decisions.
Time Frame for Health and Physical
24 hours following admission and require that the history and
physical be completed by the practitioner who is admitting the
patient. CMS Conditions of participation require that the h&P be
completed no more the 30 days before or 24 hours after admission
and the report must be placed in the record with 24 hours after
admission.
Chief Complaint
,Nature and duration of the symptoms that caused the patient to seek
medical attention as stated in his or her own words.
Present Illness
Detailed chronological description of the development of the patients
illness, from the appearance of the first symptom to present.
Past Medical History
Summary of childhood and adult illnesses and conditions, such as
infectious diseases, pregnancies, allergies and drug sensitivities,
accidents, operations, hospitalizations, and current medications.
Social and Personal History
Marital status; dietary, sleep and exercise patterns; use of coffee,
tobacco, alcohol, and other drugs; occupation; home environment;
daily routine; and so on.
Family Medical History
Diseases among relatives in which heredity or contact might play a
role, such as allergies, cancer, and infectious, psychiatric, metabolic,
endocrine, cardiovascular, and renal diseases; health status or cause
of and age at death for immediate relatives.
Review of Systems
Systematic inventory designed to uncover current or past subjective
symptoms that includes the following types of data:
* General: Usual weight, recent weight changes, fever, weakness,
fatigue
* Skin: Rashes, eruptions, dryness, cyanosis, jaundice; changes in
skin, hair, or nails
* Head: Headache (duration, severity, character, location)
* Eyes: Glasses or contact lenses, last eye examination, glaucoma,
cataracts, eyestrain, pain, diplopia, redness, lacrimation,
inflammation, blurring
* Ears: Hearing, discharge, tinnitus, dizziness, pain
, * Nose: Head colds, epistaxis, discharges, obstruction, postnasal
drip, sinus pain
* Mouth and throat: Condition of teeth and gums, last dental
examination, soreness, redness, hoarseness, difficulty in swallowing
* Respiratory System: Chest pain, wheezing, cough, dyspnea, sputum
(color and quantity), hemoptysis, asthma, bronchitis, emphysema,
pneumonia, tuberculosis, pleurisy, last chest x-ray
*Neurological System: Fainting, blackouts, seizures, paralysis,
tingling, tremors, memory loss
* Musculoskeletal System: Joint pain or stiffness, arthritis, gout
backache, muscle pain, cramps, swelling, redness, limitation in motor
activity
*Cardiovascular System: Chest pain, rheumatic fever, tachycardia,
palpitation, high blood pressure, edema, vertigo, faintness, varicose
veins, thrombophlebitis
*Gastrointestinal System: appetite, thirst, nausea, vomiting,
hematemesis, rectal bleeding, change in bowel habits, diarrhea,
constipation, indigestion, food intolerance, flatus, hemorrhoids,
jaundice
*Urinary System: Frequent or painful urination, nocturia, pyuria,
hematuria, incontinence, urinary infections
*Genitoreproductive System: Male - venereal disease, sores,
discharge from penis, hernias, testicular pain, or masses; Female -
age at menarche, frequency and duration of menstruation,
dysmenorrhea, menorrhagia, symptoms of meonpause,
contraception, pregnancies, deliveries, abortions, last Pap smear
* Endocrine System: Thyroid disease; heat or cold intolerance;
excessive sweating, thirst, hunger, or urination
* Hematological System: Anemia, easy bruising or bleeding, pas
transfustions
* Psychiatric Disorders: Insomnia, headache, nightmares, personality
disorders, anxiety disorders, mood disorders
Discharge Summary
Examination (2025-2026) Version with Questions
and Answers / Already Graded A+
Copy/Paste Functionality
Should be prevented by creating organizational policies. Problem with
this occurrence accuracy of the health record, certify the record as a
legal document when the original source is difficult to establish, and
disclosure of information to the wrong patient.
Record Retention Policies
Allows the HIM professional to know what data needs to be
maintained.
Patient Identity Management
Is a huge issue in today's connected environment. Ensuring that the
right patient is connected with the right information relies on accurate
patient identity management. Master Patient Index (MPI)
(Note: The care provider is responsible for ensuring that EHR entries
are High Quality.)
EHR Entry Policies
1. Entries must be authenticated and dated ( Name + Status)
2. All paper entries should be in ink
3. No erasures or deletions should be made
4. If correcting a paper record, one like should be drawn neatly
thought the error, leaving the incorrect material legible. The error
should be initialed and dated. In an EHR the error should be noted +
hidden. ( not deleted)
,5. Original reports should be always kept. Scans + lab results may be
replaced.
6. No blank spaces in process and nurse notes. If blanks mark with an
X.
7. All blanks should be completed. Especially, on consent forms.
8. When health records are filed incomplete, a statement should be
attached to indicate the case, signed by chief of staff or chair of the
health record committee.
9. Chart folder labeling, dotting, or other methods of identifying at a
glance a particular type of patient, such as one with a drug or alcohol
diagnosis or HIV- Positive status, should be discouraged to prevent
inadvertent breaches of confidentiality.
Advance Directive
A written document, such as a living will, that states the patient's
preferences for care in the event that the patients condition prevents
him or her from making care decisions.
Durable Power of Attorney
Is a document that names someone to make decisions from the
patient if the patient is unable to make these decisions. The person is
often called a proxy. Goes into effect when the physician determines
the patient is no longer able to communicate about health care
decisions.
Time Frame for Health and Physical
24 hours following admission and require that the history and
physical be completed by the practitioner who is admitting the
patient. CMS Conditions of participation require that the h&P be
completed no more the 30 days before or 24 hours after admission
and the report must be placed in the record with 24 hours after
admission.
Chief Complaint
,Nature and duration of the symptoms that caused the patient to seek
medical attention as stated in his or her own words.
Present Illness
Detailed chronological description of the development of the patients
illness, from the appearance of the first symptom to present.
Past Medical History
Summary of childhood and adult illnesses and conditions, such as
infectious diseases, pregnancies, allergies and drug sensitivities,
accidents, operations, hospitalizations, and current medications.
Social and Personal History
Marital status; dietary, sleep and exercise patterns; use of coffee,
tobacco, alcohol, and other drugs; occupation; home environment;
daily routine; and so on.
Family Medical History
Diseases among relatives in which heredity or contact might play a
role, such as allergies, cancer, and infectious, psychiatric, metabolic,
endocrine, cardiovascular, and renal diseases; health status or cause
of and age at death for immediate relatives.
Review of Systems
Systematic inventory designed to uncover current or past subjective
symptoms that includes the following types of data:
* General: Usual weight, recent weight changes, fever, weakness,
fatigue
* Skin: Rashes, eruptions, dryness, cyanosis, jaundice; changes in
skin, hair, or nails
* Head: Headache (duration, severity, character, location)
* Eyes: Glasses or contact lenses, last eye examination, glaucoma,
cataracts, eyestrain, pain, diplopia, redness, lacrimation,
inflammation, blurring
* Ears: Hearing, discharge, tinnitus, dizziness, pain
, * Nose: Head colds, epistaxis, discharges, obstruction, postnasal
drip, sinus pain
* Mouth and throat: Condition of teeth and gums, last dental
examination, soreness, redness, hoarseness, difficulty in swallowing
* Respiratory System: Chest pain, wheezing, cough, dyspnea, sputum
(color and quantity), hemoptysis, asthma, bronchitis, emphysema,
pneumonia, tuberculosis, pleurisy, last chest x-ray
*Neurological System: Fainting, blackouts, seizures, paralysis,
tingling, tremors, memory loss
* Musculoskeletal System: Joint pain or stiffness, arthritis, gout
backache, muscle pain, cramps, swelling, redness, limitation in motor
activity
*Cardiovascular System: Chest pain, rheumatic fever, tachycardia,
palpitation, high blood pressure, edema, vertigo, faintness, varicose
veins, thrombophlebitis
*Gastrointestinal System: appetite, thirst, nausea, vomiting,
hematemesis, rectal bleeding, change in bowel habits, diarrhea,
constipation, indigestion, food intolerance, flatus, hemorrhoids,
jaundice
*Urinary System: Frequent or painful urination, nocturia, pyuria,
hematuria, incontinence, urinary infections
*Genitoreproductive System: Male - venereal disease, sores,
discharge from penis, hernias, testicular pain, or masses; Female -
age at menarche, frequency and duration of menstruation,
dysmenorrhea, menorrhagia, symptoms of meonpause,
contraception, pregnancies, deliveries, abortions, last Pap smear
* Endocrine System: Thyroid disease; heat or cold intolerance;
excessive sweating, thirst, hunger, or urination
* Hematological System: Anemia, easy bruising or bleeding, pas
transfustions
* Psychiatric Disorders: Insomnia, headache, nightmares, personality
disorders, anxiety disorders, mood disorders
Discharge Summary
